Practice Essentials
Nearly every organ system can be affected by cocaine toxicity. Aside from alcohol (and not including tobacco-related illnesses), cocaine is the most common cause of drug-related emergency department (ED) visits in the United States, accounting for 505,224 ED visits in 2011, or 162.1 ED visits per 100,000 population. [1] See the image below.

Lab studies
If history is absent or if the patient has moderate to severe toxicity, appropriate laboratory tests may be ordered, including the following:
Complete blood count (CBC)
Electrolytes, blood urea nitrogen (BUN), creatinine, glucose (chem-7)
Glucose
Pregnancy test
Calcium
Arterial blood gases (ABG) analysis
Creatine kinase (CK) level
Urinalysis (UA): Can aid in finding cocaine-induced rhabdomyolysis, the reported incidence of which is 5-30% in ED patients who use cocaine
Toxicology evaluations: Including for urine, blood, gastric contents, and unknown substances clinging to the patient’s body
See Workup for more detail.
Radiography
Chest radiographs, which should be obtained in patients with chest pain, hypoxia, or moderate to severe cocaine toxicity, may reveal the following:
Diffuse granulomatous changes: In cases of chronic parenteral cocaine use, due to the injection of inert insoluble ingredients of oral preparations or insolubles used to cut cocaine (eg, talc)
Septic pulmonary emboli: Appear round or wedge shaped; they may clear rapidly or cavitate
Aspiration pneumonitis and noncardiogenic pulmonary edema
Pulmonary abscess: May become evident after aspiration pneumonitis or after an intravenous injection of bacteria or toxic organic or inorganic materials
Aneurysm or pseudoaneurysm: May be noted with mainlining, directly injecting into a central artery or vein; this finding is an indication for further imaging studies
In addition, radiography may be useful for evaluating cellulitis, an abscess, or a nonhealing wound in an intravenous drug user revealing foreign body or subcutaneous emphysema produced by gas-forming organisms in an anaerobic infection. Ultrasonography may identify a foreign body or abscess.
Skeletal images can reveal osteomyelitis or fractures. However, because osteomyelitis may not be demonstrable on plain images for 1-2 weeks, other imaging studies should be performed if such a diagnosis is considered.
Electrocardiography
Obtain a 12-lead electrocardiogram (ECG) in patients with chest pain; hypoxia; dyspnea; an irregular, rapid, or slow pulse; altered mental status; or moderate to severe toxicity.
Management

The general objectives of pharmacotherapeutic intervention in cocaine toxicity are to reduce the CNS and cardiovascular effects of the drug by using benzodiazepines initially and then to control clinically significant tachycardia and hypertension while simultaneously attempting to limit deleterious drug interactions.
Hyperthermia and rhabdomyolysis
If psychostimulant-intoxicated patients do not die as a result of cardiac or cerebrovascular complications, it is essential to prevent further morbidity by controlling hyperthermia and treating rhabdomyolysis.
Hyperthermia may be treated with convection cooling, which involves spraying the patient’s exposed body with tepid water as fans circulate air.
Rapid fluid resuscitation promotes urine output and alleviates the effect of myoglobin on the kidneys. Generous amounts of intravenous fluids with close monitoring of urine output and pH are indicated for rhabdomyolysis associated with severe psychostimulant toxicity.
See Treatment and Medication for more detail.